Acute Care Flashcards
15 year old with hypertensive emergency. List two medications that you can use to lower BP acutely.
For each medication, list one side-effect (not including hypotension).
IV medications
- labetolol: bradycardia, bronchospasm in asthmatics
- nicardipine: tachycardia, hypokalemia
- sodium nitroprusside: dizziness, cyanide toxicity (if malnourished or hepatic impairment)
A 15 year old child is being transferred to your centre after an MVC in which he sustained a closed
head injury. Which of the following is likely to occur on transport and will cause significant sequelae?
Hypotension
- Which of the following is least associated with increased intracranial pressure?
TCA overdose
- What is the appropriate ETT tube size for a 2 year old? (1)
Uncuffed= (2/4) + 4= 4.5
age in years/4+4
A 4-year-old with CP is involved in an MVA. He has been in the ICU for 1 week with a GCS of 4.
There is no improvement despite aggressive management and mechanical ventilation.
Parents approach you regarding the withdrawal of treatment.
Discuss the options again with the parents, and if they remain certain about the
decision then proceed with withdrawal
Notes: 3 components (2 examinations at separate times of 12-24h) o Irreversible coma with known cause o Absence of brainstem reflexes o Apnea
- Regarding consent for organ donation, which is true:
b) can consent to donation of organs despite the absence of full brain death criteria
- 4 “medical reasons” why brain dead patient may not be able to be an organ donor.
Contraindications:
- active CMV, Hep B or Hep C infection
- active extracranial malignancy
- severe, untreated systemic sepsis
- AIDS
- viral encephalitis
- risk of rare viral or prion protein illness like Creutzfeld-Jakob
- active West Nile virus or rabies
- active disseminated TB
- A boy is struck by lightning in a field. Most likely consequence?
c. cardiovascular collapse
- EKG kid in vfib/ maybe early torsades?. Patient has CPR being performed already intubated. Has IV.
Give the interventions and drugs that will be administered for his cardiac care in the first 5 minutes of
resuscitation.
CPR Shock CPR Shock CPR Epi CPR Shock Amiodarone or Lidocaine \+/- Mag Sulf if TDP (from long QT)
- Child with pulseless wide-complex tach, got defibrillated x 1 and is receiving CPR. IV is in situ. What
do you do next?
a. shock
c. epinephrine 1:10000, 0.1 cc/kg
Reversible causes of cardiac arrest?
- H’s: hypovolemia
- hypoxia
- hydrogen (acidosis)
- hyper/hypokalemia
- hypoglycemia
- hypothermia
- T’s: tension pneumo
- tamponande
- toxins
- thrombosis (pulmonary or coronary)
- unrecognized trauma
Asystole A. epi
Bradycardia B high dose epi
SVT C Atropine
V. tach with pulse D adenosine
V tach without pulse E. amiodarone
Pulseless electrical activity F. Lidocaine
Asystole: epi bradycardia: epi or atropine (if increased vagal tone) SVT: adenosine V tach with pulse: amiodarone/adenosine Pulsesless V tach: defib, then epic PEA: epi
- Child with 15% blood loss after MVA. ETA to ER is at least 1 hour. Which of the vital signs most
represents the patient upon arrival to ER.
a. pulse 120, RR 30, BP 90/60
- Can lose up to 30% of blood before BP decreases
- 15% is between very mild to mild hemorrhage
- A teenager is seen in the ER with shortness of breath. He has distended neck veins, hepatomegaly
and an S3 and an S4. What are two abnormalities on this CXR? What are two possible diagnoses?
- Cardiomegaly and Left pleural effusion ?perivascular markings
Causes heart failure in adolescent - Myocarditis
- Acute hypertension (glomerulonephritis)
- Genetic or metabolic cardiomyopathy
- Thyrotoxicosis
- Babe in shock with Na 131, K 5.9. What is the BEST thing to do right now?
b. NS bolus
- 3 yo with trauma, skull and femur fracture and has already received 3 boluses of 20 cc/kg. HR 160,
low BP – unchanged Next step:
c) inotropes and packed RBC
Notes: - to improve cardiac output
- medication therapy for hemorrhagic hypovolemic shock: vasoactive agents not
routinely indicated but patients with persistent hypotension may require short
course of something like epinephrine to restore cardiac contractility and vascular
tone until adequate fluid resuscitation is provided
- Description of toxic shock syndrome with erythema, fever, low BP. Already received 2x20cc/kg.
Slightly decreased LOC. Next?
a) bolus and inotropes. (norepi best as distributive shock)
- Infant with temp 40C, BP 70/30, HR 160. Diffuse skin erythema. Refractory to 20 cc/kg bolus normal
saline X 3. Slightly decreased LOC. Next step?
b. Inotropes and re-bolus
- Newborn term, Appropriate GA baby, cried at birth, Apgars 9 and 9. Few hours later found to be in
respiratory distress. RR 80, HR high. Cap refill 4-5 seconds, BP 48/32. Hyperinflated chest with minimal
indrawing. Cannot hear breath sounds on left, cannot hear heart sounds. Baby is turning cyanotic. What
investigation do you do (1)? What is your possible diagnosis (1) Baby’s heart rate is now 80 and is more
cyanotic. What one investigation do you want to do (1)
Transillumination. 2 nd choice: CXR
● False (+): ELBW, subcutaneous air or edema, PIE
● CXR would confirm but is clinical diagnosis
Tension Pneumothorax, DDX: Congenital Diaphragmatic Hernia.
● CC: sudden deterioration with O2 desat/increased O2 need
● Tachycardia, fall in BP
● Circulatory compromise due to mediastinal shift (pressure on RA= lower preload and CO) =
bradycardic due to hypoxemic
Treatment: Needle Decompression
● Butterfly needle (23 gauge if > 32 GA or > 1500g) + 3 way stop cock and syringe
● Insert into 2 nd intercostal space mid-clavicle line (just above 3 rd rib)
● Advance while aspirating until pull air back; and shoot out through different port; repeat
- 2 diagnostic criteria for ARDS.
- within 1 week of known clinical insult or new or worsening resp symptoms
- bilateral opacity on CXR not explained by effusion, collapse or nodules
- resp failure not explained by cardiac failure or fluid overload
- Oxygenation issues (PaO2/FiO2 less than 300 with PEEP 5 or more)
- What are two life-threatening acute presentations of a teenage boy with an anterior mediastinal
mass? State the acute presentation, and describe why it is life-threatening
Risks (compression)
o Airway compromise (airway obstruction/ respiratory failure)
o Cardiac tamponade (obstructive shock)
o Vascular Obstruction (SVC syndrome) (obstructive shock)
What are 5 causes of mediastinal mass?
Etiology (5Ts- thymoma, terrible lymphoma, teratoma, ectopic thyroid, dilated thoracic aorta)
- Child in status asthmaticus who has been given inhaled beta agonists, ipratroprium bromide and iv
steroids. Heʼs still in trouble. What are FOUR other medications that can be tried?
IV Ventolin/epinephrine
Magnesium Sulfate
Heliox
Theophylline
- Toxic child with high fever, respiratory distress. White-out on 1 side of the lung on CXR. What to do?
b. chest ultrasound
Notes: Whiteout Hemithorax DDx: large pleural effusion, empyema, hemothorax, complete lung collapse,
community acquired pneumonia, pleural masses
- Name 4 clinical signs or symptoms of a tension pneumothorax. Where would you insert a needle and
what size needle would you use. In one line describe the purpose of a Heimlich or flutter valve.
Clinical signs of a tension pneumothorax:
- respiratory distress with tachypnea and increased work of breathing
- tracheal deviation toward contralateral side
- hyperresonance of affected side
- hyperexpansion of affected side
- diminished breath sounds on affected side
- pulsus paradoxus (decrease in SBP by >10mmHg during inspiration)
Mgmt: 18-20 gauge needle and catheter over the top of the third rib (second intercostal space) in
the midclavicular line
Heimlich: - one way valve mechanism within a thoracostomy tube or tube drainage system that allows air and fluid to exit the pleural space, but prevents air or fluid from entering the pleural cavity from the outside (now we use water seal instead)
- 16 yo female on surgical ward in traction for femoral fracture and splenic rupture. She develops
sudden onset CP, cough and O2 sats 84%. Give 3 of the most likely causes of the sudden distress. Give
3 investigations to do to confirm diagnosis.
Pulmonary venous thromboembolism
Pulmonary fat embolism
Pneumothorax
- U/S of legs with doppler flow to look for DVT
- d-dimer (good sensitivity, poor specificity)
- Spiral CT with IV contrast
- The following scenarios can be seen in a child with meningitis. For which one of the following children
would you order a head CT?
c) a 5 year old with generalized tonic-clonic seizures on presentation
- Febrile 3 yo, seizing for 30 minutes. HR 180, RR 60, BP stable. Failed IV access. Next?
b) intranasal midazolam
- Child with flexion response to pain, incomprehensible moaning, eyes don’t open. GCS?
c. 6
- A 6 year old boy present to your ED with acute onset of headache. In the waiting room he suddenly
loses consciousness and is brought into your resuscitation room. He begins to have decorticate then
decerebrate posturing on the right side. You assess his ABCs and they are stable. What is the next step
in your management:
f. Mannitol
Note: clinical signs of impending herniation, including alterations in the respiratory pattern (e.g.,
hyperventilation; Cheyne-Stokes respirations, ataxic respirations, respiratory arrest), abnormalities of
pupil size and reactivity, loss of brainstem reflexes, and decorticate or decerebrate posturing.
- 3 indications for intubation in a trauma patient.
General reasons to intubate:
- unable to maintain effective airway
- unable to oxygenate
- unable to ventilate
Decreased level of consciousness such that patient cannot protect airway
Soft tissue injury/swelling raising concern for maintained airway patency
Injury to chest wall/lungs/heart leading to inability to maintain oxygenation or ventilation
Cardiorespiratory arrest
Secure airway for transportation
Need for diagnostic or interventional procedures that require patient cooperation
- Which fractures most specific to trauma X?
a) posterior rib fractures
- Dog bite 2 hours ago on the dorsum of the hand. Both the child’s and dog’s vaccinations are
up-to-date. On exam, full ROM of hand with mild edema. Appropriate management:
d) irrigate with saline and treat with clavulin prophylactically
- Child gets a tooth knocked out while playing. What are two things to do in your
management?
Management (permanent teeth)
- Find tooth
- Rinse tooth (don’t scrub or touch the root)
- Insert tooth into socket or in cold cows milk/isotonic solution
- Go directly to dentist
- (evaluate for other head/facial trauma)
- Child stepped on a nail that punctured the sole of his shoe and his foot. What is the most likely
organism?
o Pseudomonas
- Description of a child holding their arm flexed and pronated. He refuses to move
the arm. There is no history of trauma. What is the diagnosis?(1 line) What do you
do?(2 lines)
Pulled elbow
o Rotation of forearm into supination while applying pressure to radial head OR hyperpronation
- Bite in daycare Q. What to do:
a. Reasure mom of low risk of hiv infection
- Blunt abdominal trauma. One reason to take patient to OR for laparotomy.
perforation from a hollow viscous injury as demonstrated by pneumoperitoneum (i.e. bowel
perforation)
- Child with blunt abdominal trauma, gross hematuria, positive Diagnostic Peritoneal Lavage. What’s
next:
- Abdo CT (most helpful!)
- An 8 year sustained a severe head injury from which he has completely recovered.
The most likely long-term sequela is:
b. specific learning disability
- 12 yr old male in MVA. Closed head injury. In peripheral hospital, no ct no neuro surgery. Pt is
intubated and has IV in situ. Give three immediate interventions .
- Continuous monitoring of vital signs (if possible EtCO2)
- Ventilation to maintain normal oxygen and CO2
- Maintain normothermia
- Provide sedation/analgesic
- Fluids to maintain normovolemia and avoid hypotension
- elevate head of bed
- Child presents to the emergency room with a traumatic brain injury. What are 4 factors that can
cause secondary brain injury?
Hypoxia, Hypo/hypercarbia, Hyperthermia, Hypotension,
Hypoglycemia
- List 3 reasons to image a child with headaches.
- abnormal neuro exam (focal, raised ICP, altered LOC)
- seizures
- recent onset of severe, change in type, or neurological dysfunction
- 3 yo trauma patient with depressed skull fracture is unstable with desaturation and hypotension.
What is your next management step?
b) intubate
- Infant with skull fracture, suspect SCAN. What is the most likely bleed?
a. subdural
8 year old boy plays soccer competitively. He crashed into another player was confused and amnesic
afterwards. Now asymptomatic. He has practices every day for two weeks and then the playoffs start.
What do you tell him regarding his play (2)?
● no activity is step 1
● each step min. 24h and progression only if symptom free
● if symptoms recur then rest until resolve (24-48h) before trying again at last step where
asymptomatic
● only after symptom free 7-10 day and fully returned to school can begin medically supervised
return to play
A child playing a sports game has a head injury with transient loss of consciousness. What to do:
- Have him do mental tasks. If he succeeds, have him return to game
- Sit out for 1 week
- Sit out for 15 minutes
- Sit out for 1 week
“only after symptom free 7-10 day and fully returned to school can begin medically
supervised return to play”
Scenario of child head trauma. GCS 6 intubated and ventilated. To CT scan (CT of epidural
hematoma). Posturing and pupil blown in CT scan. What is the diagnosis? What next 3 things are in your
immediate management.
Epidural hematoma with raised ICP Mgmt: 1. Head of bed to 30 degrees 2. hyperventilate with 100% O2 3. 3% hypertonic saline IV bolus (5ml/kg) 4. Call neurosurgery
Child with head injury. Which of the following is a reason for why ketamine should not be used in this child? a. it has sympathomimetic properties b. it has negative inotropic properties c. it causes respiratory suppression
a. it has sympathomimetic properties
Notes: - ketamine dissociates the connections between the cortex and limbic system
- in lower doses releases catecholamines (sympathomimetic action) which maintain BP and
cardiac function BUT per Nelson’s can also be associated with increased ICP
A child is in the ICU with a severe head injury. The social worker thinks that the father inflicted the injuries. What to do.
a) despite accusation of abuse, decision to withdraw care must be made in communication with the parents
b) courts are to decide on withdrawal of care (unless parent’s rights taken away)
c) police must be notified before withdrawal
d) MD can make decision about withdrawal of care
a) despite accusation of abuse, decision to withdraw care must be made in communication with the parents
All are true of shaken baby syndrome except:
- homicide is the most common cause of death due to injury in kids <4y.o.
- external physical findings of shaken baby syndrome are not always present
- shaken baby syndrome does not occur after 3 years of age (AAP article says age 5)
- retinal hemorrhages are not always present
- homicide is the most common cause of death due to injury in kids <4y.o.
Teenager in a motor vehicle accident a day before and was observed in ER. Now presents with orange urine and his creatinine has tripled. What is the diagnosis?
a. renal vein thrombosis
b. rhabdomyolysis
c. glomerulonephritis
b. rhabdomyolysis
Child in MVA 24h ago discharged home after brief observation. Returning today with decreased U/O
of orange urine. Cr is rising and is unresponsive to fluids. Why?
a. Renal contusion
b. Renal artery thrombosis
c. Rhabdomyolysis
c. Rhabdomyolysis
List 3 treatments for hyperuricemia.
Allopurinol (decrease production of uric acid)
Alkalinize urine
Hydration
Diuresis
Rasburicase (enzyme that degrades uric acid)
